CurrentColorado Rocky Mountain Health PlansPolicy CSOH2025D0062.D

Edaravone (for Ohio Only)

Medical benefit drug policy for edaravone (Radicava/Radicava ORS) that applies only to Ohio; coverage decisions reference InterQual criteria and Ohio Administrative Code 5160-1-01 for medical necessity evaluations.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyEdaravone (for Ohio Only)

Policy CodePolicy CSOH2025D0062.D

Change TypeTitle changecontent updates

Effective DateJun 1, 2025

Next Review Date

Key ActionProviders must reference and meet the current InterQual guideline for Edaravone when requesting coverage and follow Ohio Administrative Code 5160-1-01 for services that are unproven or have limits.

SourceLink

POLICY UPDATE CHANGES

Title changed from 'Radicava (Edaravone)' to 'Edaravone (for Ohio Only)'.

1HCPCS codes listed

1Diagnosis codes listed

1State-specific (Ohio)

Coverage Summary & Rationale

Policy Title: Edaravone (for Ohio Only). Coverage stance: covered_with_criteria.

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Summary: Edaravone is covered when all criteria are met per InterQual: the patient meets the current InterQual guideline for Edaravone (CP: Specialty Rx Non-Oncology, Edaravone [Radicava, Radicava ORS]); the requested service is within the state of Ohio (this policy applies only to Ohio); and if a service is listed as unproven or has coverage/quantity limits, medical necessity will be evaluated using Ohio Administrative Code 5160-1-01.

Coverage Rationale / Medical Necessity

Edaravone is proven and medically necessary for the treatment of certain conditions outlined within the InterQual criteria. Coverage when ALL of the following are met:

InterQual criterion: Patient meets the current InterQual guideline criteria for Edaravone: CP: Specialty Rx Non-Oncology, Edaravone (Radicava, Radicava ORS).
Refer to the current InterQual guideline for clinical coverage criteria.
State applicability: Request is for a service within the state of Ohio (policy applies only to Ohio).
Policy applies only to Ohio.
State rule for unproven/limited services: If a service is stated as unproven or has coverage/quantity limits, medical necessity will be evaluated using Ohio Administrative Code 5160-1-01.
Ohio Administrative Code 5160-1-01 governs evaluation for unproven or limited services.

Provider Requirements & Documentation

Prior Authorization

Use InterQual criteria for prior authorization

Providers must reference and meet the current InterQual guideline for Edaravone (CP: Specialty Rx Non-Oncology, Edaravone) when requesting coverage. Medical necessity determinations will follow the InterQual criteria and, where applicable, Ohio Administrative Code 5160-1-01. Use this guidance when requesting prior authorization for edaravone.

J1301

Documentation Required

State rule applies for unproven/limited services

If services are listed as unproven or have coverage/quantity limits, document medical necessity in accordance with Ohio Administrative Code 5160-1-01. This state rule will be used to evaluate medical necessity for such services under this Ohio-only policy.

Background & Definitions

UnitedHealthcare may use third-party clinical guidance tools, such as the InterQual criteria, to assist in medical necessity determinations for therapies including edaravone. This policy is intended to assist in interpreting UnitedHealthcare standard benefit plans and references the current InterQual guideline for Edaravone (CP: Specialty Rx Non-Oncology, Edaravone [Radicava, Radicava ORS]).

When deciding coverage, federal, state (Ohio Administrative Code), or contractual requirements for benefit plan coverage must be consulted because those requirements may differ from the standard benefit plan. In the event of a conflict, federal, state (OAC), or contractual requirements govern.

InterQual: A third-party clinical criteria guidance tool used by UnitedHealthcare to determine medical necessity for specific therapies.